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August 7, 2017

Who's Who in Medicare Fraud? Who Is in Charge? Who Handles the Investigations? Who Prosecutes?

The Department of Justice (DOJ) and the Department of Health and Human Services (HHS) are in charge of Medicare fraud at the Cabinet level, where the Attorney General (AG) and the Secretary of HHS are directly involved. The Centers for Medicare & Medicaid Services (CMS), which operates the two programs, is within HHS.
The Health Care Fraud Prevention and Enforcement Action Team (HEAT) is a combined initiative by the DOJ and HHS. It is a team of medical experts, law enforcement, data analysts and policy staff who collaborate to identify suspicious activity and to quickly investigate and prosecute criminal behavior, as follows:

Investigations:
??? The CMS is involved in the initial stages of an investigation, as the first line of defense. Once a formal investigation begins, the Medicare Fraud Strike Force takes over. The Medicare Fraud Strike Force includes the Federal Bureau of Investigation (FBI), which is the DOJ???s primary investigative and enforcement arm, and the Office of the Inspector General (OIG), HHS??? primary investigative agency.

Prosecutions:
??? Criminal: the DOJ and 94 U.S. attorneys across the country that pursue both civil and criminal cases.
??? Civil: the Civil Division of the DOJ, which recovers funds collected from settlements and returns them to the Medicare Trust Funds.

Fraud Prevention:

??? The CMS Center for Program Integrity monitors Medicare payments for errors and collects monies owed. The CMS oversees private contractors who perform audits and review claims, and who look for fraud, abuse and waste in the system.

Related FAQs
How Much Money Is Lost to Medicare Fraud Annually?
Several Bills Have Been Introduced in Congress Regarding Medicare Fraud. Will Any of Them Become Law?
How Many Medicare Claims Are Processed by the Centers for Medicare & Medicaid Services (CMS) per Day?
How Does the Government Recover Money From Those Who Have Committed Medicare Fraud?
Have Doctors and Other Providers and Suppliers Been Excluded From Medicare Because of Fraud, Abuse or Waste? Is There a List of Those Who Have Been Excluded?